A buffalo hump is a visible buildup of fat at the base of the back of your neck, creating a rounded lump between your shoulders. The fat pad typically spans from the third cervical vertebra to the third thoracic vertebra, roughly the area where your neck meets your upper back. It’s not a bone problem or a spinal deformity. It’s dense fatty tissue that accumulates in response to hormonal imbalances, certain medications, or other metabolic conditions.
What Causes a Buffalo Hump
The most common cause is prolonged exposure to high levels of cortisol, the body’s primary stress hormone. This can happen in several ways. Cushing’s syndrome, a condition where the body produces too much cortisol on its own (often from a tumor on the pituitary or adrenal gland), is the classic medical cause. Long-term use of corticosteroid medications for conditions like asthma, arthritis, or autoimmune diseases can produce the same effect.
Certain HIV medications are also linked to fat redistribution. Protease inhibitors and a class of drugs called nucleoside reverse transcriptase inhibitors (NRTIs) can disrupt how fat cells function and how the body handles lipid and glucose metabolism. These medications may cause fat to accumulate in specific areas like the upper back and abdomen while thinning it from the face, arms, and legs. Notably, once fat accumulation starts from protease inhibitors, stopping the medication doesn’t reliably reverse it.
Obesity, particularly when combined with poor posture, can also contribute. In some cases, the cause is less clear-cut and involves a combination of metabolic factors.
Buffalo Hump vs. Dowager’s Hump
These two conditions look similar and are easy to confuse, but they’re fundamentally different. A buffalo hump is a fat deposit. A dowager’s hump (medically called kyphosis) is a structural curvature of the upper spine, often caused by osteoporosis or compression fractures in older adults. The fat in a buffalo hump is harder and denser than typical body fat, which is partly why people sometimes mistake it for a spinal problem when they touch it. Imaging like an X-ray or MRI can distinguish between the two when there’s any doubt.
How It’s Diagnosed
A doctor can usually identify a buffalo hump on a physical exam, but figuring out the underlying cause takes more work. If Cushing’s syndrome is suspected, the standard first step is measuring cortisol levels. Normally, cortisol runs between 5 and 25 micrograms per deciliter in the early morning and drops below 1.8 by midnight. A 24-hour urine collection showing cortisol above 120 micrograms is elevated in almost all cases of Cushing’s. Midnight salivary cortisol tests are also used, typically collected on two or three separate nights to improve accuracy.
If cortisol levels are normal, your doctor will look at your medication history, HIV status, and overall metabolic profile to identify other explanations.
Treatment Options
Treating the underlying cause is always the first priority. If corticosteroid medication is driving the fat accumulation, tapering the dose (under medical supervision) may help. If Cushing’s syndrome is the culprit, addressing the source of excess cortisol, whether through surgery on a tumor or other interventions, is essential before the hump will shrink. For HIV-related fat redistribution, switching away from the specific drugs most associated with lipodystrophy is standard practice, though this doesn’t always reverse fat that has already accumulated.
Reducing caloric intake remains a foundational approach across all forms of lipodystrophy. While it won’t specifically target the fat pad, lowering the overall metabolic burden on fat cells can help.
Medication for HIV-Related Fat Changes
For people with HIV-associated lipodystrophy, a medication called tesamorelin is FDA-approved to reduce excess abdominal fat. In clinical trials, patients taking it saw a 14 to 18 percent reduction in deep abdominal fat over 26 weeks, compared to essentially no change with a placebo. It’s a daily injection and is specifically indicated for HIV-related fat redistribution, not for buffalo humps from other causes.
Surgical Removal
When the fat pad is large, painful, or significantly affecting quality of life, surgery is an option. Two main approaches exist: liposuction, which suctions out the fat through small incisions, and excisional lipectomy, which cuts the tissue out directly. Some surgeons prefer excisional lipectomy because the fat in a buffalo hump contains dense, fibrous tissue that doesn’t always respond well to suction alone. For fat pads larger than 10 centimeters, combining excision with liposuction at the edges can improve cosmetic results.
The biggest concern with surgery is recurrence. Reported relapse rates run as high as 50 percent within one to two and a half years, particularly if the underlying cause isn’t controlled. One small study of nine patients who underwent excisional lipectomy found no recurrences over a median follow-up of two years, with all patients reporting satisfaction. However, about 22 percent of those patients needed additional procedures due to complications like infection or wound healing problems. Recovery typically requires a hospital stay, averaging around three weeks in that study, though simpler cases can be shorter.
Can Exercise Help
Because a buffalo hump is a fat deposit rather than a postural or skeletal issue, stretching and chiropractic manipulation won’t eliminate it. That said, strengthening the surrounding muscles and improving your posture can reduce how pronounced it looks and may prevent it from worsening. Chin tucks, core exercises, and upper body strengthening are commonly recommended. Simple habits also matter: sitting upright at your desk, keeping your neck straight when using your phone, and avoiding long periods of leaning forward with your head down.
These changes won’t replace medical treatment for the underlying cause, but they can improve your comfort and the overall appearance of your neck and upper back while other treatments take effect.